Health inspection·January 9, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review the facility failed to respond to call lights timely for 4 of 6 residents (R2, R3, R5, R6) reviewed for accommodation of needs in the sample of 6. Residents Affected - Some Findings include: 1. On 1/7/25 at 10:35 AM, R3 stated sometimes it can take a long time for her call light to be answered and for her to get cleaned up. R3 stated it is worse during supper time and at night. R3 stated the average wait time during the night is an hour. R3 stated sometimes the staff will come in her room, turn her call light off and tell her she has to wait her turn and then they leave the room. R3 stated right now she is wet with urine and needs cleaned up, she put her call light on about five minutes ago and an unknown CNA (Certified Nurse's Assistant) came into her room and told her she had to get help from staff on the other side of the building and then would be back to clean her up. On 1/7/25 at 10:46 AM, R3's stated no one has come back to help her. R3's call light was not activated at this time. On 1/7/25 at 10:53 AM, R3 stated no one has come back to help her. R3 activated her call light. On 1/7/25 at 10:58 AM, R3's call light was turned off by V9, CNA, and then V9 left R3's room. On 1/7/25 at 11:03 AM, V9 returned to R3's room and provided incontinent care to R3. R3's MDS (Minimum Data Set), dated 11/12/24, documents R3 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R3 is cognitively intact. 2. On 1/7/25 at 8:25 AM, R2 stated two nights ago, at approximately 7:30 PM, he turned his call light on, and it took an hour and a half to get it answered. R2 stated the staff ignore his call light at night. R2 stated he is continent of his bladder, but he takes a water pill, so if he has to wait too long, he will urinate on himself. R2 stated he is clean and dry at this time. R2's MDS, dated [DATE], documents R2 has a BIMS score of 15, indicating R2 is cognitively intact. 3. On 1/7/25 at 12:25 PM, R5 stated it can take a long time to have her call light answered when there is only one CNA working on the hallway for 30 residents, it's impossible. R5 stated she is clean and dry at this time. R5's MDS, dated [DATE], documents R5 has a BIMS score of 15, indicating R5 is cognitively intact. Page 1 of 2 145456 145456 01/09/2025 Lakeside Health & Rehab Center 1200 University Avenue Carlinville, IL 62626

F 0558 Level of Harm - Minimal harm or potential for actual harm 4. On 1/9/25 at 9:25 AM, R6 stated sometimes she has to wait a long time for her call light to be answered. R6 stated it happens during the day and at night. R6 stated she has had incontinent episodes due to having to wait on staff to respond to her call light. R6's MDS, dated [DATE], documents R6 has a BIMS score of 13, indicating R6 is cognitively intact. Residents Affected - Some The Resident Council Minutes, dated 12/18/24, documents there were concerns with call lights. On 1/9/25 at 10:05 AM, V14, Activity Director, stated there were resident that voiced concerns in the December 2024 resident council meeting that it was taking a few minutes before staff came in their room to answer their call light. On 1/9/25 at 10:20 AM, V1, Administrator, stated the expectation is that call lights will be answered in a timely manner. A reasonable time depends on the resident, some want care right then and if staff are assisting other resident's, it can take a few minutes, but they do get to them as soon as they can. The Call Light Guidance Policy, dated 7/1/23, documents resident call lights shall be responded to within a reasonable amount of time. 145456 Page 2 of 2